Grant Application | The Brave Little Bears Foundation

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Grant Application

Please note: To qualify for a grant from The Brave Little Bears Foundation, the person receiving the grant must (1) be a resident of Montgomery County, PA; (2) have a documented developmental disability; and (3) be under 18 or be 18 and over but not be their own legal guardian. If those criteria have been met, please complete the form below.

Part I. Personal Information: Person Completing this Form

First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region*

Address*

Address - line 2

City*

Zip / Postal code*

Marital status*

Single

Married

Divorced

Separated

Widowed

Employment status*

Employer

Occupation

Relation to applicant*

Are you the legal guardian of the grant applicant?*

Yes

No

How did you hear about this grant opportunity?*

Part II. Personal Information: Grant Applicant

Full Legal Name*

Address (leave blank if same as above)

Birthday*

Month

Day

Year

Race/Ethnicity*

Gender

Does the applicant have secondary insurance through the State of PA?*

Yes

No

Diagnosis (check all that apply)*

Autism Spectrum Disorder

ADHD

Down Syndrome

Cerebral Palsy

Intellectual Disability

Learning Disability

Other

Description of Developmental Disability*

Please upload documentation of a developmental disability diagnosis - remove any sensitive information. Proof may include a medical form, first page of an IEP, therapy evaluation, etc. *

Does the applicant have any other medical conditions? *

Yes

No

Current services/therapies applicant is receiving either through PUBLIC services (early intervention, county, school district) or COVERED INSURANCE (check all that apply)*

Occupational Therapy

Physical Therapy

Special Instruction

Mobility & Orientation Therapy

Speech Therapy

Feeding Therapy

Vision Therapy

Parent-Child Interaction Therapy (PCIT)

Reading Support

Math Support

Applied Behavioral Analysis Therapy (ABA)

Psychotherapy/Talk Therapy/Counseling

Personal Care Assistant

Home Health Aide

None

Other

List all other therapies, specialized activities, and/or recreational programs in which the applicant is participating that are either free or paid for privately

Type of school (select all that apply):

Public

Private

Charter

Parochial

Special Education

Therapeutic

Other

Name of current school placement or educational program, if any:

Is there an Individualized Education Program (IEP) and/or 504 Plan in place?

Has the applicant applied for or received funding from another nonprofit or outside source related to their developmental disability? (For informational purposes only.) If yes, from where and how much?

Part III. Family Information

What is the combined gross annual income of the legal guardian responsible for the individual with a developmental disability?*

<$50k

$50k–$74,999

$75k–$99,999

≥$100k

You may be asked for your previous years’ tax return if the applicant is selected to receive the grant.

Is the applicant a minor (under 18 years old)?*

List the total number of dependents currently under the care of the legal guardian of the grant applicant (including the grant applicant)*

Number of other dependents with a developmental disability, if any

Family Story: Enter any information you would like us to know about the applicant and the applicant’s family that may be helpful in the grant award process.

Part VI. Grant Request Details

For which grant are you applying? (check one only)*

Therapy Grant (up to $3,000)

Activity Grant (Ranging from $250 up to $2500)

Recreational Access Grant (Ranging from $100 up to $500)

Describe how the applicant will use this grant. Be as specific as possible.*

List names of any providers, vendors, therapy practices, etc. with which you plan to use the grant funds if awarded. Write unknown if not yet known.*

Should the applicant be awarded a grant, the recipient will have up to six months to select a provider and have that provider approved by The BLBF. The BLBF may be able to provide assistance locating a provider should the recipient need it.

Describe how this grant will impact the applicant. Be as detailed as possible.*

This therapy or activity is:*

Not covered by insurance.

Sometimes covered by insurance.

Never covered by insurance.

The answer to the above question will not impact your application status.

Is there a deadline associated with this request?

Enter the amount of funding that you are requesting (can be an estimate): Therapy Grant - Up to $3000 Activities Grant - Up to $2500 Recreational Access Grant - Up to $500*

Please provide any additional comments that may be relevant to this grant application.

By submitting this grant application, I agree that if the applicant is awarded and accepts a grant from The Brave Little Bears Foundation, the applicant and their legal guardian agree to provide a testimonial about their experience with the foundation and a photo of the grant recipient for use in the foundation's marketing materials, on its website, and on social media.

MISSION STATEMENT

The Brave Little Bears Foundation is dedicated to providing financial assistance and support to families with children who have developmental disabilities, enabling them to access private therapies, specialized activities, and mainstream recreational programs that are otherwise out of reach. Our goal is to alleviate the unique burdens these families face, ensuring they have the resources to support their children’s happiness, development, and well-being.

little bears. big possibilities. X o

CONTACT >

T: 215-380-6053

E: info@thebravelittlebearsfoundation.org

TERMS & CONDITIONS + PRIVACY POLICY

ACCESSIBILITY STATEMENT

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